1. Israel Freeman, MD Associate Professor of Clinical Medicine
Pericardial Diseases
Israel Freeman, MD
Associate Professor of Clinical Medicine

2. Diseases of the Pericardium
Acute Pericarditis
Pericardial Effusion
Constrictive Pericarditis

3. Acute Pericarditis

4. Acute Pericarditis common causes
Outpatient setting
usually idiopathic
probably due to viral infections
Coxsackie A and B (highly cardiotropic) are the most common viral cause of pericarditis and myocarditis
Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV

5. Diseases of the Pericardium
Acute Pericarditis
Primary:
Usually due to viral infection Course brief and usually uncomplicated
Secondary
Result from other conditions: rheumatic or collagen diseases, radiotherapy or rend failure related, often exhibit clinical feature, similar to acute pericarditis

6. Acute Pericarditis common causes
In-patient setting T = Trauma, TUMOR U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine, procainamide) O = Other infections (bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder, Radiation

7. Special Ethiologic Forms of acute Pericarditis and Pericardial Effusion
Renal failure and dialysis: more extensive dialysis and NSAID is usually successful occasionally pericardocentesis necessary
unexpected drop of B.P during dialysis may be the clue
Radiation induced pericardial effusion:
After radiation to the mediastinum
May evolve into constrictive Pericarditis after many years
Neoplastic pericardial effusion
Accounts for 50% of patient with tamponade
Lung, Breast cancers accounts for majority of causes, lymphomas and leukemia also important causes
Purulent Pericarditis: usually requires surgical draming
Drug induced Pericarditis: Procainamide, Minoxidil, Methylsergide
Post Cardiotomy Syndrome

8. Acute Pericarditis Diagnostic Clues
History
sudden onset of anterior chest pain that
is pleuritic and substernal
Physical exam
presence of two- or three-component rub
ECG
most important laboratory clue

9. Acute Pericarditis Differential Diagnosis
Acute myocardial infarction
Pulmonary embolism
Pneumonia
Aortic dissection

10. Acute Pericarditis Chest Pain History pericarditis vs infarction
Common characteristics
retrosternl or precordial with raditaion to the neck, back, left shoulder or arm
Special characteristics (pericarditis)
more likely to be sharp and pleuritic
 with coughing, inspiration, swallowing
worse by lying supine, relieved by sitting and leaning forward

11. Acute Pericarditis Heart Murmurs of Pericarditis
Pericardial friction rub is pathognomic for pericarditis
scratching or grating sound
Classically three components:
presystolic rub during atrial filling
ventricular systolic rub (loudest)
ventricular diastolic rub (after A2P2

12. Acute Pericarditis
ECG in stage 1 of pericarditis shows PR segment depression and ST elevations.

13. Stages of ECG Evolution in Acute Pericarditis
PR segments
ST segments
T waves 1
Depressed
Elevated
Upright 2
Isoelectric
Isoelectric
Flat 3
Isoelectric
Isoelectric
Inverted 4
Isoelectric
Isoelectric
Upright

14. ECG in Acute Pericarditis
EKG contrast the pattern of ST segment elevation characteristic of acute pericarditis (a) with the normal variant (early repolarization) pattern of ST segment elevation (b). The normal variant pattern is associated with a normal or slow heart rate and has relatively tall R waves and T waves in V4, V5, and V6. The ST segment elevation is less than 25% of the T wave amplitude. In contrast, the acute pericarditis has PR depression and lower T wave.

16. Acute Pericarditis ECG features
ST-segment elevation
reflecting epicardial inflammation
leads I, II, aVL, and V3-V6
lead aVR usually shows ST depression
ST concave upward
ST in AMI concave downward like a “dome”
PR segment depression
early stage
T-wave inversion
occurs after the ST returns to baseline

17. Pericarditis
Acute apical infarction
Early Repolarization

18. Acute Pericarditis Management
Analgesic agents
codeine mg q 4-6 hr
Anti-inflmmatory agents
Treat underlying cause
ASA 648 mg q 3-4 hrs
NSAID (indomethacin mg qid)
Corticosteroids are symptomatically effective , but preferably avoided

19. Acute Pericarditis Diagnosis Treatment Chest pain
Friction rub, fever, Tachycardia
EKG changes are common (diffuse ST-T changes with absence of reciprocal ST depression when ST elevation is present, depressed PR segment)
Mild elevation of cardiac enzymes
Treatment
Analgesics – codeine, hydrocodone
NSAID – Indomethacin (100 mg/d)
Corticosteroids – (40 – 60 mg/d) , slow tapering (2 – 4 weeks) due to possible recurrence after steroid withdrawal

20. Other forms of Acute Pericarditis
Relapsing Pericarditis
Acute Pericarditis of any etiology may relapse
Treatment: Colchicine, Prednisone or immnosuppressants
Progression to constriction
Rarely acute pericarditis progresses to subucute / chromic

21. Other Forms of Pericarditis Dressler’s Syndrome
Described by Dressler in 1956
fever, pericarditis, pleuritis (typically with a low grade fever and a pericardial friction rub)
occurs in the first few days to several weeks following MI or heart surgery
incidence of 6-25%
treat with high-dose aspirin

22. Other Forms of Pericarditis Bacterial Pericarditis
Rare condition in antibiotic era (steadily decreased over last 40 years)
Typically arises from contiguous spread of intrathoracic infection (pneumonia, empyema, mediastinitis, endocarditis, trauma, surgery)
Usually fatal without adequate treatment
Diagnosis frequently missed
Often lacks characteristic features of acute pericarditis

23. Other Forms of Pericarditis Purulent Pericarditis (data from 15 patients)# 3 2
mediastinitis esophageal tear, dental abscess retropharyngeal abscess, chest trauma, post-cardiac surgery infection
endocarditis, prosthetic aortic valve
pneumonia (with empyema)
hepatic abscess (with empyema)
bacterial meningitis
diabetes, leukemia, bone marrow transplant 1 1 1 1 3
Arch Int Med 1996; 156:1857

24. Other Forms of Pericarditis Tuberculous Pericarditis
Incidence of pericarditis in patients with pulmonary TB ranged from 1-8%
Physical findings: fever, pericardial friction rub, hepatomegaly
TB skin test usually positive
Fluid smear for TB often negative
Pericardial biopsy more definitive

26. Acute Pericarditis Key Points
• Acute pericarditis is accompanied by pericardial effusion in 60% of cases and tamponade in as many as 15% of cases.
• Outpatient management of acute idiopathic pericarditis is acceptable if there is no effusion at predischarge echocardiography and surveillance can be provided at home.
• In the care of patients in clinically stable condition who are being hospitalized, echocardiography should be performed in the first 24 hours because a large effusion is the best predictor of poor outcome

27. Pericardial Effusion and Cardiac Tamponade

28. Pericardial Effusion and Cardiac Tamponade
Fluid can accumalte in the pericardium in any form of pericardial disease
Transudate
Exudate
Serosanguineous: Idopathic, dialysis-related, neoplastic, radiation induced, TB, coagulapaties
Bloody: Coagulopathies, trauma, rupture in MI and in aortic dissection
Cardiac Tamponade is the most important complication of fluid accumulation

29. Cardiac Tamponade pathophysiology
Fluid accumulation within the pericardial space resulting in
increased intracardiac pressure
progressive limitation of ventricular diastolic filling
reduction of stroke volume and cardiac output

30. Cardiac Tamponade
The physiological effect depends on the rate of fluid accumulation
Gradually the pericardium may strech and accommodate > 2,000 ml
Acutely as little as 200 ml of accumulated fluid may raise the intrapercardial pressure to cause tamponade
JVD elevated (rarely not in low pressure tamponade)
B.P variable, paradoxical pulse (>10 mm HG )
Echocardiography
Treatment: fluids, pericardiocentesis, cardiac surgery.

32. Cardiac Tamponade Beck’s Triad
Described in 1935 by thoracic surgeon Claude S. Beck
3 features of acute tamponade
Decline in systemic arterial pressure
Elevation in systemic venous pressure (e.g. distended neck vein)
A small, quiet heart

33. Etiologies of Cardiac Tamponade
malignancy
idiopathic pericarditis
uremia
acute myocardial infarction
diagnostic procedures with cardiac perforation
bacterial
tuberculosis
radiation
myxedema
dissecting aortic aneurysm
post pericardiotomy syndrome
systemic lupus erythematosus
cardiomyopathy

34. Cardiac Tamponade Early stage Advanced stage
mild to moderate elevation of central venous pressure
Advanced stage
 intrapericardial pressure  ventricular filling,  stroke volume
hypotension
impaired organ perfusion

35. Cardiac Tamponade Clinical Features
Symptoms
dyspnea, fatigue, agitation and restlessness, syncope, shock, anuria
Physical examination
pulsus paradoxus
tachycardia
increased jugular venous pressure
hypotension

36. Cardiac Tamponade Pulsus Paradoxus tamponade without pulsus
atrial septal defect
severe aortic stenosis
aortic insufficiency
left ventricular dysfunction LVH with  LVEDP
decreased intravascular volume (low-pressure tamponade)
pulsus without tamponade
COPD
RV infarct
pulmonary embolism
effusive constrictive pericarditis
restrictive cardiomyopathy
extreme obesity
tense ascites

37. Central Venous Pressure
Cardiac Tamponade
Central Venous Pressure
X - descent
descent of the base in systole
Y - descent
occurs as the tricuspid valve opens and ventricular filling begins from the high-pressure right atrium
in constrictive pericarditis, filling is truncated in early to mid diastole
in tamponade, filling is restricted throughout diastole
Kussmaul’s Sign
in constriction, venous return increases with inspiration and a high right atrial pressure resists filling resulting in an increased JVP

38. Central Venous Pressure
Cardiac Tamponade
Constrictive Pericarditis
presence of a rapid Y-descent argues against cardiac tamponade

39. Cardiac Tamponade Pulsus Paradoxus
an exaggerated drop in SBP with inspiration (>10mmHg)

40. Pressure Readings in Cardiac Tamponade
The aortic pressure and right atrial pressure are recorded during quiet breathing in a patient with cardiac tamponade. The marked fall in arterial pressure that occurs during inspiration is a paradoxical pulse. The decrease in pulse pressure, defined as the difference between systolic and diastolic pressures, that accompanies the fall in systolic pressure indicates that left ventricular stroke volume decreases during inspiration. Central venous pressure, as indicated by the right atrial pressure, also falls during inspiration.

41. Cardiac Tamponade Dignostic Evaluation Chest x-ray Echocardiography
usually requires > 200 ml of fluid
cannot distin guish between pericardial effusion and cardiomegly
Echocardiography
standard for diagnosing pericardial effusion
convenient, highly reliable, cost effective
false positives (M-mode)- left pleural effusion, epicardial fat, tumor tissue, pericardial cysts

42. ECG in Pericardial Effusion
Diffuse low voltage
amount of fluid
electrical conductivity of the fluid
Electrical alternans
alternating amplitude of the QRS
produced by heart swinging motion
also seen in PSVT, HTN, ischemia

44. ECG: Pericardial Effusion
The electrocardiogram (V2 lead) from a patient with pericardial effusion caused by malignant melanoma reveals a low voltage and electrical alternans.

45. Echocardiographic Diagnosis
Cardiac Tamponade
Echocardiographic Diagnosis
Pericardial effusion
highly reliable
Cardiac tamponade
RA and RV diastolic collapse
reduced chamber size
distension of the inferior vena cava
exaggerated respiratory variation of the mitral and tricuspid valve flow velocities

46. Pericardial Effusion-Echocardiography
Pericardial effusion is seen in the two-dimensional echocardiogram as an echo-free space outside the cardiac chambers. Two characteristic sites are lateral to the left ventricle in the apical four-chamber view (shown here) and posterior to the left ventricle in the parasternal long-axis view (see Figure 3b).

47. RA and RV diastolic collapse
early diatole
systole
late
diastole

48. CT Scan: Pericardial Effusion
A chest CT scan of a patient with pericardial effusion, pericardial fluid appears less dense than the heart and is separated from the myocardium by epicardial fat in some areas.

49. Echocardiogram: Pericardial Effusion
The echocardiogram demonstrates that the heart moves forward (F) and backward (B) within the effusion on alternate beats, thus producing the alternation of the QRS axis characteristic of electrical alternans. The heart also moves with inspiration (Insp) and expiration (Exp), which accounts for a change in anterior wall motion with every two cardiac cycles.

50. Differential Diagnosis of Cardiac Tamponade vs
Differential Diagnosis of Cardiac Tamponade vs. Chronic Constrictive Pericarditis
Differences between the central venous pulse contours characteristic of cardiac tamponade (left) and chronic constrictive pericarditis (right) provide the basis for differential diagnosis. The pressure contour in a patient with pericardial effusion and tamponade has a prominent systolic dip (X) but little or no diastolic deflection. The central venous pulse pattern in a patient with chronic constrictive pericarditis displays an M or W contour consisting of both systolic dip (X) and diastolic dip (Y), the Y descent being more prominent.

51. CT Scan in Chronic Constrictive Pericarditis
In this CT scan of the chest of a patient with chronic constrictive pericarditis, the dense layer on the anterior surface of the heart represents thickened and partially calcified pericardium.

52. Cardiac Tamponade Treatment Options
Nonsurgical
pericardiocentesis
blind
ECG guided
Echo guided
CT guided
balloon pericardiotomy
Surgical
subxiphoid
video-assisted thoracoscopy
pericardial-peritoneal
pericardial window
pericardiectomy

53. Cardiac Tamponade Pericardiocentesis Diagnostic tap
usually not indicated
rarely have positive cytology or infection that can be diagnosed
Therapeutic drainage
indicated for significant elevation of the central venous pressure

54. Cardiac Tamponade Pericardial Window
Balloon dilatation of a needle pericardiostomy
subxyphoid surgical pericardiostomy
video-assisted thoracoscopy with localized pericardial resection
anterolateral thoracotomy with parietal pericardial resection

55. Localized and Low Pressure
Cardiac Tamponade
Localized and Low Pressure
Localized tamponade due to loculated pericardial effusion
Low pressure tamponade due to relative intravascular volume depletion

56. Constrictive Pericarditis Idiopathic Restrictive Cardiomyopathy
Clinical Features That Differentiate Constrictive Pericarditis from Amyloidosis and Idiopathic Restrictive Cardiomyopathy
Clinical Feature
Constrictive Pericarditis
Cardiac Amyloidosis
Idiopathic Restrictive Cardiomyopathy
Early diastolic sound (S3 or pericardial knock)
Frequent
Occasional
Late diastolic sound (S4)
Rare
Atrial enlargement
Mild or absent
Marked
Atrioventricular or intraventricular conduction defect
QRS voltage
Normal or low
Low
Normal or high
Mitral or tricuspid regurgitation
Paradoxical pulse
Frequent but usually mild
Exaggerated variation in mitral and tricuspid flow velocity with respiration, out of phase
Usual

58. Constrictive Pericarditis (concretio cordis)

59. Constrictive Pericarditis
An uncommon post inflammatory disorder
the encasement of the heart by a rigid, nonpliable pericardium
characterized by a thickened, fibrotic, and frequently calcified pericardium
rarely develop after an episode of acute idiopathic pericarditis
more likely to develop after subacute pericarditis with effusion that evolve over several weeks

60. Causes of constrictive pericarditis
idiopathic
infectious
tuberculosis
virus
bacteria
histoplasmosis
drugs
hydralazine
cromolyn sodium
procainamide
penicillins
isoniazid
minoxidil
phenylbutazone
methysergide
radiation
chest trauma or surgery
epicardial defibrillator patches
connective tissue disease
SLE, RA, dermatomyositis
renal failure (on dialysis)
myocardial infarction
neoplasm
sarcoidosis
porphyria cutanea tarda
asbestosis
Whipple disease

61. Constrictive Pericarditis Differential Diagnosis
restrictive cardiomyopathy
right ventricular failure
mitral and tricuspid valve disease
cardiac tamponade

62. Constrictive Pericarditis Clinical Findings
Jugular venous elevation 96%
prominent X- and Y-descent, “M” or “W” 94%
 with inspiration (Kussmaul’s sign)
Heart
diastolic pericardial knock %
absent or decreased apical impulse
Abdomen:
ascites %
pulsatile hepatomegaly 70%
Extremities: peripheral edema
Pulsus paradoxus
almost always < 10 mm Hg; otherwise, considered tamponade

63. Constrictive Pericarditis Diagnosis
insidious onset , often not recognized in its early phases by exam, x-ray, ECG, echo
average duration of symptoms before diagnosis was 23.4 months ( range 1 to 264 months)
tendency to overlook elevated JVP
subacute chronic
diastolic knock
Kussmaul’s
pulsus paradoxus < 10 mm Hg

64. Constrictive Pericarditis Diagnostic Tests
Electrocardiogram
sinus tachycardia, atrial fibrillation, ST flattening, T-wave inversion, low QRS voltage, right axis deviation / RVH
Chest radiograph
pericardial calcification (44% to 70% in the past), must be distinguished from left ventricular aneurysm calcification
MR I and computed tomography
pericardial thickening over the right ventricle (sensitivity 88%, specificity 100%, diagnostic accuracy 93%)

65. Pericardial Calcification

66. CT Scan in Chronic Constrictive Pericarditis
In this CT scan of the chest of a patient with chronic constrictive pericarditis, the dense layer on the anterior surface of the heart represents thickened and partially calcified pericardium.

67. Constrictive Pericarditis Echocardiography
M-mode echo
abrupt flattening of mid to late diastolic movement of the LV posterior free wall
diastolic septal bounce
TTE / TEE
normal pericardium 1.2  0.8 mm
3 mm cut off has a sensitivity of 95% and specificity of 86%

68. Constrictive Pericarditis Effect of respiration on pulsed-wave Doppler pattern
Mayo Clin Proc

69. Constrictive Pericarditis Doppler vein flow velocities
pulmonary venous flow velocity
peak systolic and diastolic values decrease with inspiration

70. Constrictive Pericarditis
Hemodynamics
End-diastolic pressures
elevated and equalized (<5 mm Hg difference)
RA pressure tracing
rapid X- and Y-descent, “W” or “M” pattern
failure to decrease with inspiration (Kussmaul’s sign)
RV pressure
RVEDP > 1/3 of RVSP
dip and plateau configuration of RVDP (square root sign)
LV and RV pressures
discordant changes

71. Hemodynamics of Constrictive Physiology variability in early-daistolic PCW-LV gradient with respiration

72. Pericardiectomy cardiac decortication
Constrictive Pericarditis
Pericardiectomy cardiac decortication
In hospital mortality vary between 0% and 10%
predictors of poor outcome:
underlying malignancy
radiation-induced
previous paracardial surgery
NYHA class IV symptoms
myocardial atrophy
myocardial inflammation and scarring